Author + information
- Received September 5, 2018
- Revision received September 17, 2018
- Accepted September 25, 2018
- Published online November 14, 2018.
- Guglielmo Gallone, MDa,
- Luca Baldetti, MDa,
- Anna Palmisano, MDb,
- Francesco Ponticelli, MDa,
- Georgios Tzanis, MDa,
- Antonio Colombo, MDa,
- Antonio Esposito, MDb and
- Francesco Giannini, MDc,∗ ()
- aUnit of Cardiovascular Interventions; IRCCS San Raffaele Scientific Institute, Milan, Italy
- bDepartment of Radiology and Experimental Imaging Centre, IRCCS San Raffaele Scientific Institute, Milan, Italy
- cInterventional Cardiology Unit, GVM Care & Research Maria Cecilia Hospital, Cotignola, Italy
- ↵∗Address for correspondence:
Dr. Francesco Giannini, Interventional Cardiology Unit, GVM Care & Research Maria Cecilia Hospital, Via Madonna di Genova, 1, Cotignola 48033, Italy.
A 66-year-old man with a history of hypertension, dyslipidemia, multiple myocardial infarctions, and coronary artery bypass graft surgery presented to our clinic with Canadian Cardiovascular Society class III angina persisting despite optimal anti-ischemic therapy (metoprolol 50 mg twice daily, amlodipine besylate 10 mg, nitrate patch 10 mg/24 h, ranolazine 500 mg twice daily).
Dipyridamole stress perfusion cardiac magnetic resonance (CMR; Figures 1A to 1D), performed to assess myocardial ischemia and viability, revealed diffuse ischemia (ischemic burden 22.9%), impaired myocardial perfusion reserve (global myocardial perfusion reserve index 1.25) and diffuse myocardial fibrosis (scar burden by global late gadolinium enhancement 17%). The posterior septum and the inferior wall showed wall thinning and subendocardial late gadolinium enhancement referable to a post-ischemic scar of the right coronary artery territory (Figure 1C).
Coronary angiography documented 3-vessel coronary artery disease with patent bypass grafts and a totally occluded right coronary artery (Figures 2A to 2C). A multidisciplinary heart team evaluation contraindicated right coronary artery chronic total occlusion percutaneous coronary intervention because of absent myocardial viability in its territory and, in consideration of the high diffuse ischemic burden, a decision was made to undertake coronary sinus (CS) Reducer implantation.
A multipurpose catheter was advanced through the right internal jugular vein and the CS ostium engaged. The 9-F guiding catheter with the Reducer scaffold was advanced to the landing site and the balloon was inflated at 3 atm for 30 seconds. Final venography confirmed successful Reducer deployment and position in the CS (Figure 3).
At the 4-month outpatient visit, the patient was asymptomatic for angina and reported improved quality of life (Seattle Angina Questionnaire mean domain score improvement from 45 to 73 points). Four-month dipyridamole stress perfusion CMR (Figures 1E to 1H) showed improved perfusion parameters: ischemic burden 13.3%, global myocardial perfusion reserve index 1.61, and unchanged scar burden (late gadolinium enhancement 18%).
The CS Reducer represents a novel therapeutic option with established safety and clinical benefit in the treatment of patients with refractory angina (Figure 4) (1,2). Despite the Reducer’s unique potential in a population with a strong and currently unmet need for new therapeutic options, the interventional community does not seem to have yet truly embraced the use of this device. Although partly due to its novelty, this limited adoption seems to be also ascribed to concerns regarding the large placebo effect that is frequently observed with novel therapies for refractory angina. Indeed, although the Reducer is postulated to alleviate symptoms by improving perfusion in myocardial ischemic territories, current evidence is limited to small experiences with inadequately accurate, mostly operator-dependent imaging techniques.
Stress perfusion CMR is emerging as the noninvasive gold standard for the assessment of ischemia in patients with coronary artery disease (3). Our images provide insights into the potential impact of the CS Reducer on the ischemic burden of patients with refractory angina with coronary artery disease by means of a reliable, non-operator-dependent imaging tool such as stress perfusion CMR, thus suggesting a physiological rationale for the clinical benefit already observed with Reducer implantation.
Dr. Giannini is a consultant for Neovasc. The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received September 5, 2018.
- Revision received September 17, 2018.
- Accepted September 25, 2018.
- Giannini F.,
- Baldetti L.,
- Konigstein M.,
- et al.
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